Wednesday, January 31, 2018

Sean Fine, Globe and Mail Justice writer reported that Ontario's Divisional Court (3 - 0) decided that doctors in Ontario, who oppose killing their patients, must provide an effective referral to a physician who will kill their patient.

Effective referral means a referral for the purpose of the act. Fine reported that Justice Herman Wilton-Siegal wrote that:

"The evidence in the record establishes a real risk of a deprivation of equitable access to health care, particularly on the part of the more vulnerable members of our society, in the absence of the effective referral requirements,"

Fine reported that Albertos Polizogopoulos, an Ottawa lawyer representing 4700 doctors who were challenging the Ontario regulations argued that the effective referral mandate violates the freedom of conscience and religion protected in Section 2 of Canada's Charter of Rights and Freedoms:

"Our position is doctors who opposed assisted suicide or physician-assisted death are put in a position now where they either need to violate their conscience and their religious and moral belief or face being disciplined by the college – and that's not a good place to be,"

...most provinces do not require referrals to willing physicians. Alberta, for example, co-ordinates requests and referrals through a centre that patients can call on their own. The faith groups do not object to referring patients to the centre. Manitoba has a team of physicians willing to help the severely ill end their lives. Ontario has now set up a co-ordinating centre but faith doctors say they are still concerned that they are responsible for an "effective referral."

Fine reported that this case is the first to test the constitutional rights of doctors who object to assisted death on grounds of conscience. and the decision comes as doctors opposing assisted suicide struggle to find a middle ground. Some hospitals run by Catholic, Jewish or other religious groups have declined to offer assisted dying. In those cases, patients are transferred to other facilities.

Parliament legalized assisted death on June 17, 2016. The legislation stated in its preamble that doctors have a right to freedom of conscience, and are not required to perform or assist in the provision of an assisted death.

Tuesday, January 30, 2018

Increasingly aggressive euthanasia activists are attempting to rewrite the meaning of palliative care across Canada.

Dr Will Johnston

By Dr Will Johnston, a family physician and Chair of EPC-BC.

Canadians who are sick and suicidal can now be put to death under various medicalized and government-approved protocols, following court and legislative victories by euthanasia activists. These activists are now turning their considerable talents to a coercive makeover of the palliative hospice movement by demanding that hospices founded on a promise to never deliberately hasten death should provide a death-hastening service.

Before they got their way in the Canadian Supreme Court, the public posture of euthanasia advocates was one of caution, reassurance and limitation of objectives. After their victory, partisans of the medical killing movement have become impatient with individuals or institutions who want no part in suicide and euthanasia. Activists recommend expanding access to include all the people who were strategically excluded from the plan that had been sold to the public: children, people with chronic nonfatal conditions, the physically disabled, the cognitively disabled, psychiatric patients.

Now, even changing the location of a patient requesting suicide — from a euthanasia-free hospital or hospice, to one that does offer it — is being protested as a cruel imposition. In doing so, the death-seeking person is set up as a victim, and the hospital or hospice is portrayed as a victimizer. Never mind that hospital wards routinely transport people in complete comfort to procedures like X-rays or scopes, or to another location to continue care.

The implications of this are dire. Many hospices serve patients who want nothing to do with assisted suicide, and there will be much harm done by forcing it into their midst. Every community in this country has the resources to provide a distinct euthanasia-free space. That distinct space and its staff could be specialized and uncoerced into death-hastening.

Louis Brier home.

The unpleasant alternative was demonstrated by the recent "sneak attack" on Louis Brier Hospital, a Jewish retirement home in Vancouver. This was the work of euthanasia activist Ellen Wiebe, idolized by like-minded columnists for her aggressive death-providing practice. Rather than arrange a simple transfer — perhaps to the home of one of the suicidal father's daughters — the patient was killed by Dr. Wiebe against the firm policy of a facility with an understandable aversion to euthanasia.

As Louis Brier's director protested, "We have a lot of Holocaust survivors. To have a doctor sneak in and kill someone without telling anyone. They're going to feel like they're at risk when you learn someone was sneaking in and killing someone."

What Dr. Wiebe was doing by giving the finger to Louis Brier is a form of ethical bullying, masquerading as an altruistic claim that her client should come first and trump other people's rights about the kind of place they want to live in.

Wanting Dr. Wiebe to kill you is a tragedy, not an emergency. It is a personal preference, sadly now provided by the Canadian health-care system, but without any judicial or parliamentary authorization to force others to accept involuntary proximity to your actions. It is also, increasingly, about people who are not dying, except in Dr. Wiebe's elastic interpretation, but about those who have lost meaning and hope. What they get from the euthanasia provider amounts to a heartless endorsement of the hopelessness of their situation, cloaked in the language of autonomy.

Rather than look for a win-win compromise over this issue, the board of Fraser Health Authority, a large B.C. hospital system, has imposed euthanasia provision in all its palliative hospices. This edict, totally uncalled for by provincial or federal guidelines, caused the high-profile resignation of Palliative Care Medical Director Dr. Neil Hilliard.

Meanwhile, our governments are, in Dr. Hilliard's words, "guilty by neglect" of a "palliative care access gap," and your sick family member who seeks care, not death, may not find it "equitable or timely."

Forcing hospices to betray their no-kill founding principles will not close that gap, it will just torpedo the 40-year struggle to convince often-fearful patients that palliative hospices are not about hastening death.

Fraser Health and any other misled health bureaucracies across Canada should back down. Don't bully hospices as though there are no fair alternatives. Don't bully Catholic hospitals, founded on a reverence for life long before the public purse got involved.

The... Netherlands is completely wrong when it comes to euthanasia. He calls it a slippery slope. "Only when euthanasia became possible in physical medicine did we start developing good palliative care. That is the reverse order? Now the same thing happens in psychiatry. There is no policy for chronic patients, but we do allow euthanasia. ''

Koerselman is convinced that psychiatric patients can not make a sober, intellectual decision whether or not to live. "There are always emotions like fear, shame or anger. It is an illusion with the syndrome to think that such a decision is well-considered.''

Koerselman, who stated that he is definitely not religious, stated:

psychiatrists can not judge this. For even psychiatrists are not able to look into the patient's head in such a way that he or she can judge whether a death wish is justified. "We overestimate ourselves as a professional group."

Menno Oosterhoff, who knew Aurelia personally and who lives with compulsive disorder, is a psychiatrist who supports euthanasia for psychiatric reasons. The article states (google translated):

it is not up to the masses, or a professional group to give an opinion on one specific patient. ,, Only the patient himself, his doctor and psychiatrist can make a good estimate.

According to Oosterhoff there are too many prejudices about people with psychological problems who have a death wish. "That they have a lack of willpower is such a preconception. People's prejudices tend to be more difficult when it comes to an individual person. If you know Aurelia's story yourself. She is terminal because her soul is failing. There are too many theoretical objections to euthanasia."

Jim van Os is a professor of psychiatry who does not oppose euthanasia but is concerned that it may become too common:

There are examples of patients with a very strong death wish, who asked for euthanasia and did not get it and now a happy one life, because they have found the love of their lives, for example.

Van Os is worried about the growing demand for euthanasia in psychiatry. He does not want to go into the specific case 'Aurelia'. "But in a general sense you may wonder if we have done enough to help these people." ... How is it that someone wants to die? Should we have been unable to do something at an earlier stage? "This professor also notes that the GGZ in the Netherlands is under pressure due to cutbacks. Dangerous, he says. GGZ Nederland does not want to accept this criticism.

Psychiatrist Bram Baker, who had a friend who died by euthanasia for psychiatric reasons, set up a signature campaign opposing euthanasia for psychiatric suffering. According to the article:

He is critical: "Legally, it is allowed. But a judgment about psychic, unbearable suffering is always subjective. You can not take a position as a psychiatrist, that is very scary. And I think euthanasia is going too far. Is there no other option?

Several excellent articles have been published opposing euthanasia for psychiatric reasons.

The patient, referred to in official documents only as “2016-85,” had made an advance directive requesting euthanasia in case of dementia. But the directive was ambiguously worded, and she was no longer able to clarify her wishes by the time she was placed in a nursing home — though her husband did request euthanasia for her.

Despite the lack of a clear expression from the patient, a physician concluded her suffering was unbearable and incurable — though there was no terminal physical illness — and prepared a lethal injection.

To ensure the patient’s compliance, the doctor gave her coffee spiked with a sedative, and, when the woman still recoiled from the needle, asked family members to hold her down. After 15 minutes were spent by the doctor trying to find a vein, the lethal infusion flowed.

Lane then focuses on the case of Sarah (Aurelia) a physically healthy 29-year-old woman who is scheduled to die by assisted death for on January 26 in the Netherlands. Lane writes:

Nevertheless, a 29-year-old woman, “Sarah,” whose sole medical complaint is serious, nearly lifelong depression and self-harming behavior, has received permission for euthanasia, to take place Friday, according to the RTL Nieuws, a Dutch media outlet .

She was released from prison in December 2016 after serving 2½ years for arson. She received no therapy while incarcerated and, 12 months later, she persuaded doctors her psychological suffering was unbearable and untreatable.

“It was a long and difficult road before she finally got permission,” RTL Nieuws observed. “And that is why Sarah wants attention for her story. Not for herself, but for others who also find life psychologically too heavy, have no chance of healing and want to die in a dignified way.”

Lane then focuses on the psychiatric euthanasia deaths in Belgium:

Joris Vandenberghe, a psychiatrist at the University of Leuven, is calling for stricter controls.He complained last year that psychiatric patients have died at the hands of doctors who failed to meet criteria set forth in Belgian law: “I’m convinced that in Belgium, people have died where there were still treatment options and where there was still a chance for years and even decades of life.”

Support for the practice is still strong, so strong that the Brothers of Charity, a Roman Catholic organization that operates the largest group of psychiatric hospitals in Belgium, has agreed to acquiesce to euthanasia requests — contrary to Vatican policy.

This decision came after a Belgian court ordered a different Catholic institution to pay damages to the family of a 74-year-old terminally ill woman because administrators required her to leave the facility for euthanasia. Religious conscience was no defense, the court ruled.

Lane concludes his article by stating that the World Psychiatric Association has ducked the issue of euthanasia for psychiatric reasons.

I directed the Program in Human Rights and Health at the University of Minnesota School of Public Health from 2006-2016 and am a past chair of the American Public Health Association's Ethics Special Primary Interest Group (now Ethics Section).

While working on my dissertation I was a visiting preceptor (research rotation) at the Hennepin County (Minnesota) Medical Examiner's Office. It was greatly impressed upon me the need for scientific accuracy in the medico-legal documentations of death.

HB 160 states regarding death by lethal ingestion, "The death certificate must list the underlying terminal illness as the cause of death."

The falsification of medical-legal documents for the sake of social sensibilities and legal impunity will protect abuse by making systematic patterns non-traceable and non-prosecutable.

It constitutes a form of state-imposed corruption of physicians and registrars which does not protect the public, nor the integrity of the public health vital records and data. It is done for no other context where possible stigma is present (deaths from overdose, alcohol, or socially stigmatized diseases).

Delaware may be voting on assisted suicide bill HB 160 on January 25, 2018

Wesley Smith

By Wesley Smith

Assisted suicide/euthanasia advocates want a very broad and easy latitude to have death by overdose or lethal jab.

They hide this truth behind blithe assurances of strict protections and feigned desires to limit assisted suicide to the very few as a “safety valve.” They say it will always be limited to the competent. But sometimes, they let that cat out of the bag before legalization.

Such is the case in Delaware where the sponsor of that state’s assisted suicide legalization bill has amended the proposal to include the terminally ill ”intellectually disabled,” who by definition, will often not be able to fully comprehend the nature of what is being discussed.

“Intellectual disability” means a disability, that originated before the age of 18, characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills.”

This means disabled people with significant intellectual impairments. They could be eligible for assisted suicide if a social worker says they understand (my emphasis):

(b) If the patient has a documented intellectual disability, the attending physical shall refer the patient to a licensed clinical social worker who shall ensure that the patient fully understands the information provided pursuant to § 2504B(3).

No medication to end a patient’s life in a humane and dignified manner may be prescribed unless the licensed clinical social worker has confirmed in writing to the attending physician that the patient understands the information provided pursuant to § 2504B(3).”

These are people who can’t legally enter contracts! They can’t control where they live! They can’t make their own medical decisions! They also can’t vote, pursuant to the Delaware Constitution!

No person adjudged mentally incompetent . . . or incapacitated under the provisions of this Constitution from voting, shall enjoy the right of an elector. DEL. CONST. art. 5, § 2.

Yet, if they have a terminal illness, they are going to be able to commit assisted suicide if a social worker–who may be ideologically predisposed in favor–confirms that they “understand” that they are receiving a poison prescription?

It doesn’t even require approval of a guardian, as would corrective surgery or treatment to cure or palliate. Good grief!

Assisted suicide corrupts everything it touches. For those with eyes to see, let them see.

According to news reports Poppe allegedly killed his first victim in 1978 and his last alleged victim may have been his own mother who died in 2011.

The guardian reported that investigators examined 65 suspicious deaths and Poppe admitted to killing his mother, his step-father and two uncles.

Belgium legalized a very permissive form of euthanasia in 1992 and yet Poppe continued killing patients until 2011. This case once again proves that legalizing euthanasia does not prevent clandestine euthanasia.

Further to that, euthanasia without explicit consent is somewhat common in Belgium.

Hugh Scher, legal counsel for the Euthanasia Prevention Coalition, also responded to the Siwicki case. Scher said that debates around end-of-life care are nothing new but the Siwicki case was particularly disturbing.

“I was surprised and horrified at the notion that this is how we’re going to treat our seniors; this is how we’re going to treat those who are vulnerable and in our care, to simply leave them to die on the floor with only the most basic of food and water, and without any basic pain and symptom management,” he says. “This is a very concerning proposition as it’s clearly contrary to basic human rights obligations and to basic care obligations that we all owe as citizens and as people of this country, particularly those who are in positions of trust and authority relative to their loved ones or are healthcare providers.”

“It’s really disrespecting – to a greater extent than before – human beings and human life in a manner that really does put people who are vulnerable and in the care of others at risk. There must be exceptional efforts taken, I think, to ensure that neglect and abuse are avoided," says Scher.

Scher stated that:

“We have historically believed that the third-party killing of people is wrong.”

Sadly, now that euthanasia is legal in Canada, new pressures are being placed upon people, such as Candice Lewis, to die by euthanasia.

Sunday, January 21, 2018

A medical ethicist has resigned from a Dutch regional assessment committee for euthanasia over a law which allows non-consenting demented patients to be euthanised. For ten years Berna van Baarsen helped to assess whether euthanasia had been performed in accordance with the law in the North Holland region. She resigned on January 1.

“'I do not believe that a written declaration of intent can replace an oral request for incapacitated patients with advanced dementia,” she told the magazine Medisch Contact.

Under Article 2.2 of the Dutch euthanasia law, a doctor may euthanize a patient who can no longer make clear what he wants, but who had previously left a written declaration. The law says:

If a patient aged sixteen or over who is no longer capable of expressing his will, but before reaching this state was deemed capable of making a reasonable appraisal of his own interests, has made a written declaration requesting that his life be terminated, the physician may comply with this request unless he has well-founded reasons for declining to do so.

"In people with a terminal illness like cancer, in whom euthanasia has already been agreed but who suddenly ended up in a coma because of their illness, that's fair," says van Baarsen.

However, dementia is a very different kind of ailment, she told Trouw. "That disease is more erratic and patients often live longer. A lot of things can happen during that period. "For instance, a patient might say that she would want euthanasia if she no longer recognizes his relatives. "This could happen. But at a next visit she can still recognize her partner or her children. What is the right moment to grant euthanasia? "

Furthermore, the suffering of a dementia patient is difficult to assess.

"It is fundamentally impossible at this stage to establish that the patient is suffering unbearably, because he can no longer explain it", says van Baarsen.

Sometimes patients act aggressively after being admitted to a nursing home, even shouting that they want to leave. "It is of course possible that the patient is suffering unbearably,” she admits. “But does the same applies to a nursing home resident who is sitting quietly in a corner? If you are not entirely sure, you cannot presume that they are suffering unbearably.”

Van Baarsen is not the only member of a euthanasia review committee to resign over the interpretation of the law. Three years ago ethicist Theo Boer also stepped down and has become a harsh critic of the Dutch euthanasia system.

John Kelly, the director of the disability rights group Second Thoughts Massachusetts, wrote an excellent article on why the Massachusetts legislature must say NO to assisted suicide, that was published in the Boston Globe on January 16. In his article, Kelly states that Massachusetts Joint Committee on Public Health, which have defeated seven previous assisted suicide bills, will be debating two identical assisted suicide bills (H.1194 and S.1225). Kelly explains that assisted suicide is simply too dangerous.

Kelly then offers several examples of why assisted suicide is too dangerous. The first is that it is cheaper than treatment:

The bill, despite its promise of “end-of-life options,” ultimately takes choice away from people. Because assisted suicide would immediately become the cheapest “treatment” offered, it would encourage insurers to reject traditionally covered treatments. That’s already happening in states where assisted suicide is legal.

Dr. Brian Callister, a Nevada physician, reported earlier this year that two patients were denied routine treatments with 70 percent cure rates by their respective California and Oregon insurance companies, which offered coverage for assisted suicide instead. And again, once assisted suicide became legal in California,Stephanie Packer, a young mother with scleroderma, was denied her prescribed treatment but learned that her assisted suicide copay would be $1.20.

The second reason Kelly offers is that misdiagnosis is common:

To qualify for assisted suicide under the proposed statute, you need to have a prognosis of six months or less to live. Every year, however, doctors misjudge the time a person has left, and thousands “graduate” from their six-month “terminal illness” hospice benefit. People outlive terminal expectations all the time, like the late Senator Ted Kennedy, who lived a full year longer than his terminal diagnosis of 2 to 4 months. In 2012, Kennedy’s widow, Victoria, wrote that the additional months he lived were meaningful and productive, and left behind priceless memories.

The third reason is that the legislation is flawed:

The bill requires no official witness at the death, creating opportunities for foul play. Especially vulnerable will be the 10 percent of Massachusetts adults over the age of 60 estimated to be abused every year, almost always by family members. A caregiver or heir to an estate can witness a person’s request, pick up the prescription, and then administer the lethal dose without worry of investigation — the bill immunizes everyone involved.

Among the bills’ hollow “safeguards” is a provision requiring people who request assisted suicide to have a one-time counseling appointment to determine that the person “is capable and not suffering from a psychiatric or psychological disorder or depression causing impaired judgment.” But impairing judgment is what depression does, and few psychologists are confident they can diagnose depression in a single visit. People in the midst of a severe depression can usually present as “unimpaired,” especially in a single meeting with a counselor they’ve never met before, who is not even required to be a psychologist or psychiatrist. Depression is treatable and reversible. Suicide isn’t.

The final reason that Kelly offers is that assisted suicide changes the healthcare system:

Finally, assisted suicide sets up a two-tier system, in which “quality of life” judgments by others steer some people to suicide prevention services and others toward death. Disabled people, including people disabled by their serious illness, are especially vulnerable. A recent study in the New England Journal of Medicine described the main motive for assisted suicide requests as “existential distress.” The official reports from Oregon and Washington show that the top five reasons to request assisted suicide do not even include pain, but rather distress over dependence on others, loss of abilities, bodily shame, incontinence, and feeling like a burden.

People with disabilities generally oppose assisted suicide because it threatens their equality rights:

We disabled people reject the idea that the dependent aspects of our daily lives make our lives undignified.

Opposition to assisted suicide is centered in communities of color and the working class. Black and Latino voters, opposed to assisted suicide by more than 2-to-1, effectively defeated assisted-suicide ballot Question 2 in 2012. People historically disrespected and neglected by our health care system are rightly suspicious of the power to prescribe death.

Saturday, January 20, 2018

We’ve seen it happen: A new assault on the sanctity of human life appears—say, infanticide being promoted in a major bioethics journal, or officials in Iceland bragging that no children with Down syndrome are born there, thanks to prenatal genetic screening—and some horrified opponents respond in horror, “That’s what the Nazis did!” It’s an easy accusation to wield, but rarely a wise one. Often, these proposals and policies have little to do with the crimes of Hitler and his minions—and a great deal to do with the eugenicist movement that preceded them.

Take the euthanasia killings of people with disabilities in the Netherlands, Belgium, and Canada. Certain analogies to Nazi horrors spring to mind: German doctors killed disabled babies between 1939 and 1945—as is happening today in the Netherlands, despite being technically illegal. And German doctors terminated disabled adults in hospitals. In the latter example, however, there are some crucial differences. Unlike legal voluntary euthanasia of disabled people in Belgium, the Netherlands, and Canada, the disabled victims of the Nazis were part of mass killing experiments at the start of the Holocaust. And since people who are accused of Nazi thinking don’t appear threatening—they don’t wear “SS” insignia on tailored black leather coats or boast funny mustaches, and they haven’t swallowed the poisonous ideology of fascism—the Nazi epithet is more likely to undermine the accuser’s credibility than persuade his audience.

So, what are we supposed to do, Wesley? Ignore history? Not at all. In fact, I think a more apt thought connection to the culture-of-death practices and proposals of today can be made to the invidious beliefs that animated eugenics—a movement still disdained by most people. This analogy is less likely to be rejected out of hand.

Here’s an example. Many people believe that German crimes in the medical context were Hitler’s idea, or were purely a product of Nazi ideology. Not true. The doctors who committed these crimes had embraced the eugenicist ideology that views some lives as of lower “quality” and, hence, lower value than others. The support among German medical, legal, and academic intelligentsia for euthanasia and terminating the disabled long predated Hitler’s rise to power.

Medical historian Robert Jay Lifton has identified the 1920 book Allowing the Destruction of Life Not Worthy of Life (Die Freigabe der Vernichtung Lebensunwerten Lebens), written by law professor Karl Binding and physician Alfred Hoche, as “the crucial work” promoting the agenda of death. Permitting the Destruction of Life profoundly influenced the values of the general public and the ethics of the German medical and legal communities—to the point that a 1925 poll of the parents of disabled children reported that 74 percent of them would agree to the painless killing of their own children!

The book is a truly chilling read, not only because of its crass advocacy for killing the defenseless, but also because of the ways in which it mirrors many concepts propounded by bioethicists and euthanasia advocates today. Binding and Hoche believed that some lives are so degraded that they constitute “life not worthy of life.” Who were these unfortunates?

Terminally ill or mortally wounded individuals who “have been irretrievably lost as a result of illness or injury, who fully understand their situation, possess and have somehow expressed an urgent wish for release.” This view is virtually identical to the euthanasia and assisted suicide policies urged upon us today.

Binding and Hoche believed it was permissible to euthanize “incurable idiots,” whose lives they denigrated as “pointless” and “valueless.” They were deemed an economic and emotional “burden on society and their families.” Today’s advocates do not depict the developmentally disabled as “idiots,” nor do most go as far as Hoche and Binding did in calling for non-voluntary killing. However, the economic cost of caring for those labeled as having a low quality of life is frequently noted by euthanasia advocates and asserted as grounds for healthcare rationing and the withdrawal of wanted life support.

The “unconscious,” who “if they ever again were roused from their comatose state, would waken to nameless suffering.” The United States and other Western nations already allow terminating such individuals by withholding tube-supplied sustenance—as vividly exposed in the legal and cultural conflagration over the court-ordered dehydration death of Terri Schiavo.

More explicit eugenics advocacy of the era is also analogous to culture-of-death arguments made today. From around the 1910s through the end of World War II, eugenicists promoted not only involuntary sterilization of the so-called “unfit,” but also infanticide of disabled babies (which was not carried out beyond Germany). Helen Keller, of all people, argued that killing disabled children was merely the “weeding of the human garden,” apparently believing that she would be spared because her significant disabilities were not congenital. The eugenicist and social Darwinist Margaret Sanger also used the “weeds” metaphor to support the infanticide of “human waste.” Such denigrating terms are not deployed today, but how are those views different from the public policies that support aborting fetuses with Down syndrome and other genetic conditions?

Once again, we are in a time of pronounced danger for the medically vulnerable. Once again, the prospect of medical cleansing casts a dark shadow over the ethics of healthcare and the practice of clinical medicine. But to the opponents of these policies, I say: Yes, support the equality and sanctity of human life. Yes, when appropriate, bring up historical precedents. But leave the Nazis out of it. If that point is going to have any chance of resonating, let your listener come to that conclusion on his own, which will make it more likely to stick.

The sad fact is that not every wrong idea or wicked public policy is traceable to Hitler. There are many other paths off the ethical cliff.

Tuesday, January 16, 2018

When my mother was in her final months, suffering from a heart failure and other problems, she called me to her bedside with a pained expression. She took my hand and asked plaintively, “How do I get out of this mess?”

As a physician, I dreaded the question that might follow: Would I help her end her life by prescribing a lethal drug?

Fortunately for me, my mother tolerated her final weeks at home, with the help of hospice nurses and occasional palliative medication. She never raised the thorny question of what is variously termed “medical aid in dying” or “physician-assisted suicide.”

As a son and family member who has witnessed the difficult final days of parents and loved ones, I can understand why support for MAID/PAS is growing among the general public. But as a physician and medical ethicist, I believe that MAID/PAS flies in the face of a 2,000-year imperative of Hippocratic medicine: “Do no harm to the patient.”

Studies point out that even many doctors who actually participate in MAID/PAS remain uneasy or “conflicted” about it. In this piece, I explore their ambivalence.

Assisted suicides

In discussing end-of-life issues, both the general public and physicians themselves need to distinguish three different approaches.

MAID/PAS involves a physician’s providing the patient with a prescription of a lethal drug that the patient could take anytime to end life. In contrast, active euthanasia or “mercy killing” involves causing the death of a person, typically through a lethal injection given by a physician. Finally, the term “passive euthanasia” refers to hastening the death of a terminally ill person by removing some vital form of support. An example would be disconnecting a respirator.

Increasing international acceptance

In the U.S. some form of legislatively approved MAID/PAS (but not active euthanasia) is legal in five states and the District of Columbia. In my home state – following a passionate debate – the Massachusetts Medical Society recently decided to rescind its long-held opposition to the practice. MMS has taken a position of “neutral engagement,” which it claims will allow it to “serve as a medical and scientific resource … that will support shared decision making between terminally ill patients and their trusted physicians.”

In a few countries, MAID/PAS has grown increasingly common. In Canada, for example, MAID/PAS was legalized in 2016. In Belgium and the Netherlands, both active euthanasia and physician-assisted suicide are permitted by law, even for patients whose illnesses may be treatable, as with major depression; and whose informed consent may be compromised, as in Alzheimer’s disease. In the Netherlands, a proposed “Completed Life Bill” would allow any persons age 75 or over who decide their life is “complete” to be euthanized – even if the person is otherwise healthy.

Perhaps this trend is not surprising. After all, what sort of physician would want to deny dying patients the option of ending their suffering and avoiding an agonizing, painful death?

But this question is misleading. Most persons requesting PAS are not actively experiencing extreme suffering or inadequate pain control. Data from the Washington and Oregon PAS programs show that most patients choose PAS because they fear loss of dignity and control over their own lives.

Some physicians feel conflicted

Physicians who carry out assisted suicide have a wide variety of emotional and psychological responses. In a structured, in-depth telephone interview survey of 38 U.S. oncologists who reported participating in euthanasia or PAS, more than half of the physicians received “comfort” from having carried out euthanasia or PAS.

“Comfort” was not explicitly defined, but, for example, these physicians felt that they had helped patients end their lives in the way the patients wished. However, nearly a quarter of the physicians regretted their actions. Another 16 percent reported that the emotional burden of performing euthanasia or PAS adversely affected their medical practice.

For example, one physician felt so “burned out” that he moved from the city in which he was practicing to a small town.

Other data support the observation that MAID/PAS can be emotionally disturbing to the physician.

Kenneth R. Stevens Jr., an emeritus professor at Oregon Health and Science University, reported that for some physicians in Oregon, participation in PAS was very stressful. For example, in 1998, the first year of Oregon’s “Death with Dignity Act,” 14 physicians wrote prescriptions for lethal medications for the 15 patients who died from physician-assisted suicide.

The state’s annual 1998 report observed that:

“For some of these physicians, the process of participating in physician-assisted suicide exacted a large emotional toll, as reflected by such comments as, ‘It was an excruciating thing to do … it made me rethink life’s priorities,’ ‘This was really hard on me, especially being there when he took the pills,’ and ‘This had a tremendous emotional impact.’”

As a physician and medical ethicist, I am opposed to any form of physician assistance with a patient’s suicide. Furthermore, I believe that the term “medical aid in dying” allows physicians to avoid the harsh truth that they are helping patients kill themselves. This is also the view of the very influential American College of Physicians.

I believe that the ambivalence and discomfort experienced by a substantial percentage of PAS-participating physicians is directly connected to the Hippocratic Oath – arguably, the most important foundational document in medical ethics. The Oath clearly states:

“I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.”

In 5th century BC Greece, Hippocrates was something of a revolutionary in this respect. As the classicist and medical historian, Ludwig Edelstein has pointed out some non-Hippocratic physicians probably did provide poisons to their dying patients, in order to spare them protracted suffering. Hippocrates opposed this practice, though he did not believe that terminally ill patients should be exposed to unnecessary and futile medical treatment.

“From its very inception, the profession of medicine has formally prohibited its members from using their special knowledge to cause death or harm to others. This was – and is – a necessary protection so that the power of medicine is not used against vulnerable people.”

Indeed, when patients nearing the end of life express fears of losing control, or being deprived of dignity, compassionate and supportive counseling is called for – not assistance in committing suicide.

To be sure, comprehensive palliative care, including home hospice nursing, should be provided to the subset of terminally ill patients who require pain relief. But as physician and ethicist Leon Kass has put it: